Abstract: The ritual status of niddah generally results from uterine bleeding not due to injury. The most common situation is menstruation; other causes may include bleeding from hormonal contraception or treatment, bleeding during pregnancy or with ovulation, and inter-menstrual bleeding from medical conditions. The niddah status can also result from cervical dilatation during certain medical procedures. A similar status (yoledet) is attained with childbirth.

Jewish law (halacha) prohibits all physical contact (not only intercourse), and proscribes certain other behaviors, between a married couple while the wife has the status of niddah.

A woman remains in the status of niddah until all bleeding has ceased, an additional seven days with no bleeding have elapsed, and she has immersed in a kosher ritual bath (mikveh). After the woman has exited the niddah status, marital relations are permitted and encouraged until she once again anticipates the onset of her menses.

Discussion:

The Niddah Status

A woman enters the ritual status of niddah when she experiences uterine bleeding not due to injury. While menstruation is the most common cause of this status, the term "niddah" is not synonymous with menstruation. Other causes may include withdrawal and breakthrough bleeding from hormonal contraception, side effects of hormonal treatment, bleeding during pregnancy and at the time of ovulation, and inter-menstrual bleeding resulting from medical conditions such as endometriosis. The niddah status can also result from cervical dilatation during certain medical procedures, or from hymenal bleeding following sexual intercourse. A similar status (yoledet) is attained with childbirth; identical laws apply to the niddah and to the yoledet.

Jewish law forbids all physical contact (not only intercourse) between a husband and wife while she is niddah. Certain other behaviors are forbidden as well - for example: passing objects to each other, sitting on the same surface, sleeping in the same bed, eating from the same plate, and seeing each other undressed.

It should be noted that for both menses and inter-menstrual bleeding, niddah can result from even small amounts of spotting. Thus bleeding that has little clinical significance can lead to long periods of physical separation between husband and wife, with the attendant stress and strain.

Hargashah - Sensation

According to Biblical law, a woman becomes niddah only if her bleeding is accompanied by a bodily sensation (hargashah). While there is no Talmudic description of the physical sensation, various definitions have been offered by rabbinic authorities, including a bodily tremble associated with the onset of the menstrual flow, feeling of urination, opening of the uterus, and sensation of an internal blood flow from the cervix. Although some women report experiencing such a sensation, most current halachic literature considers it unusual.

According to rabbinic law, which is completely binding, the onset of niddah does not require hargashah. Therefore, a flow of uterine blood (as distinguished from light, intermittent, staining) will render a woman niddah even in the absence of hargashah.

Staining

Light, intermittent staining, unaccompanied by hargashah, can render a woman niddah. A stain will result in niddah only if it is of a minimum size, reddish or black in color, and found on a white surface. If it is found on a synthetic substance, there may be room for leniency as well. Sometimes strategies designed to take advantage of these leniencies (e.g., wearing colored undergarments, changing underwear frequently to prevent the accumulation of small stains or, according to some opinions, wearing panty liners of synthetic material) may be used under rabbinic guidance to avoid becoming niddah from staining. These leniencies may not apply to certain stains, such as those found immediately following intercourse, immediately following urination, or on an internal self examination (bedikah as described below).

Exiting the Niddah Status

A woman who has entered the status of niddah or yoledet remains in that state, regardless of how many days she actually bleeds, until she has fulfilled all of the following criteria:

1. She has stopped bleeding. She must verify this by performing an internal examination, known as the hefsek taharah, during which she inserts a white cloth (known as a bedikah cloth) deep into the vaginal canal. She removes the cloth immediately and checks it for blood. If there is no indication of bleeding, the examination is successful and she proceeds to the next step. The hefsek taharah examination is crucial and cannot be omitted.

Note: Most women then insert a second bedikah cloth, known as the moch dachuk, just prior to sunset. This cloth remains inside the vagina for about 20-72 minutes, depending on the woman's custom. Like a tampon, it should not be forgotten or left inside for an extended period. The moch dachuk is a customary practice that should be followed, but can, upon the advice of a rabbi, be omitted if indicated by circumstances such as a friable vaginal lining.

2. A minimum of twelve days have elapsed since the onset of her niddah status. This is divided in to two phases:

a) The five-day minimum. Even if her menses are short, she must still wait five days before the onset of the second phase. Some women of Sephardic background wait four days rather than five.

b) Seven "clean" or "white" days. During this week, the woman verifies that bleeding has not recurred by doing two internal examinations (bedikot) daily. The procedure is identical to that for the hefsek taharah examination. If these examinations are painful, their number can be somewhat reduced upon the advice of a rabbi. During the seven clean days, women generally wear white underwear in order to remain aware of any spotting or staining. If a woman finds blood on an internal examination or a halachically significant stain on her underwear, she needs to perform a new hefsek taharah and begin counting the seven clean days all over again. She does not have to repeat the five-day minimum.

3. She has immersed in the mikveh (ritual bath). For proper immersion in the mikveh, she must remove any foreign substance that adheres to her body, including medical items such as bandages and stitches. If a barrier cannot be removed for medical reasons, she must consult with a rabbi to see if it is permissible for her to immerse.

Anticipation of Menses

To minimize the chances of intercourse taking place just when the wife becomes niddah, there are certain days around the time of her anticipated menses on which intercourse is forbidden. These are called onot perishah, or "times of separation." During these days - generally the same Hebrew date as the onset of her previous menses, and/or after the same interval as that which separated her last two menses, and/or after a 30-day interval - intercourse is forbidden but other physical contact is permitted. It should be noted that the intervals are counted differently than medical intervals in that the last day of one interval is also the first day of the next. Therefore, a 30-day halachic interval is medically a 29-day cycle. Furthermore, if a woman has consistent physical symptoms indicating the onset of menses (veset haguf), she must also observe an onat perishah during the time she experiences these symptoms.

Non-niddah Bleeding

Bleeding from other parts of the female genital tract, such as the vagina and the vaginal part of the cervix, does not render a woman niddah. Regarding bleeding from the endocervix there is debate among the authorities; however, most halachic authorities rule that bleeding from the area of the external os does not render a woman niddah. If a stain can be reasonably attributed to a source other than the uterus, she does not become a niddah. Also, bleeding resulting from injury such as lacerations, abrasions or side effects of operative or diagnostic procedures is referred to as dam makkah (bleeding from a wound) and does not render a woman niddah, regardless of location.

It is important to note that the religious terms and medical terms overlap but are not synonymous. A "makkah" is any lesion that could explain the bleeding, even if it is not a medical illness. Such a lesion should be reported to the woman so she may relay the information to her rabbi for a halachic ruling. The rabbi's ruling depends on various factors, including where she is in her cycle. The healthcare professional's role is to provide an accurate, non-judgmental report of the physical findings.

Gynecological Procedures

The scheduling of gynecological examinations and procedures is particularly important for women observing niddah, since the examinations often cause bleeding. From the time she has immersed in the mikveh until she anticipates her next period, a woman has a halachic presumption of not being niddah and observed blood can generally be assumed to be of traumatic origin. If blood is found during the seven "clean" days (especially during the first three), it is halachically more difficult to attribute it to a wound, since bleeding during this time may be considered a continuation of her menstrual flow. Likewise, if invasive gynecologic procedures are performed close to the day of expected menstruation, any staining or bleeding could be considered menstrual blood.

Implications for Patient Care: The laws of niddah are complex, and are not merely a prohibition on marital relations during menstruation.

It is important that physicians understand the full scope of these practices in order to provide their patients with optimal medical care.

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